Last Helicopter Out of Saigon!

In popular psychiatry, a classic passive aggressive gambit is “malicious compliance”- intentionally inflicting harm on someone by strictly following a directive, even though the person knows that they are damaging someone by doing so. In Washington, the most skilled practitioner of this dark art is Speaker Nancy Pelosi If health reform craters, Pelosi will disingenuously claim that she did precisely what the President asked of her, and blame the Senate and the President for its failure.

In reality, Pelosi’s “leadership” almost fatally wounded health reform last summer. If the process does collapse, the blame should fall squarely on her shoulders. Her poor political judgment led directly not only to squandering a nearly 80 vote majority, but also exposed embarrassing and ill-timed disunity among Democrats on a signature domestic policy issue. It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.

Last July 14, Speaker Pelosi unveiled the opening bid in the health reform process- HR 3200, America’s Affordable Health Choices Act of 2009. This bill was drafted largely without input from their Republican colleagues or from important Democratic moderates. It also put into legislative language virtually exactly what the President promised in his campaign, without considering seriously the political implications for the actual passage of the legislation- a political form of malicious compliance. Democratic moderates felt their input had been ignored and they were immediately trapped on the wrong side of this issue.

HR3200 had an immediate polarizing effect on the health reform debate, and the damage control process was on. In a sense, health reform has never recovered. Pelosi’s bill summoned the right wing talk radio demons (and the inimitable Betsy McCaughey) out of their caves, reviving long dormant rhetoric about a “government takeover of the health system”. This label has clung stubbornly to all subsequent versions of the legislation.

Unfortunately, the critics weren’t too far wrong. HR 3200 effectively federalized the employer health benefit. It mandated that employers offer a “one size fits everyone” health benefit to their workers, the benefit precisely defined by federal statute. It imposed an 8% payroll tax on employers who did not provide the benefit, pushing their federal payroll tax to 23% if you include Social Security and Medicare. It also moved the top tax rate for federal income taxes for businesses filing as “subchapter S” to 46%, a level not seen since Jimmy Carter was in the White House.

Given unemployment was climbing toward 10% at the time, HR3200 would have simultaneously diminished corporate cash flow and increased the cost of hiring new workers for firms that did not presently offer health coverage- a recipe for no recovery.

HR 3200 created new health insurance premium subsidy for workers covering and estimated 20 million new people, but without any meaningful brake on future federal subsidies. To enroll these new folk, however, health insurers would have to comply with provisions of a new federal health insurance exchange, whose rules would have effectively ended medical underwriting.

The health coverage gated through the exchange was no longer be “insurance”, but a federally defined health care entitlement financed largely by employers. The bill also created a public health insurance option, which had the effect simultaneously of competing with and financially undermining private health insurers. All of this was to be overseen by a politically appointed Health Choices Commissioner, in effect, a commissar for the health insurance system. This nominally private-sector approach had a distinctly Soviet flavor.

Almost immediately upon HR3200’s release and for the following seven months, the Democrats have been playing defense on health reform and losing. Democrats elected from Red or Purple states ran from the bill as fast as their legs would carry them. They rebelled against the “public option”, the employer mandates, as well as the tax increases required to fund the premium subsidies.

Moderate Democrats also objected to subsidizing private coverage of abortions and to any enrollment of people in the US illegally (roughly 7-8 million of the uninsured). It might have been possible to address these concerns “privately”, e.g. in the initial drafting process, but by the time HR 3200 was released, many After almost four months of contentious negotiations, a revised version of the House bill passed by only five votes, one of which came from a stray Republican.

By the time Democratic moderate concerns had been clumsily and publicly accommodated (in the late fall), the resulting House bill had gravely offended three core constituencies of the Democratic party- women, Hispanics and the single-payer advocates, without materially addressing the critics of a huge expansion of federal power (and spending). The Democratic base lost enthusiasm for the bill while Democratic moderates continued to struggle with the “government takeover” label. By late fall, the legislation had acquired the odor and toxic sheen of a rotten side of tuna.

In the court of public opinion, the ensuing seven months (with a brief blip after Labor Day after a well- crafted Obama defense of health reform), were all down hill for health reform. Opposition to the process, as much as the substance, of health reform hardened, aided materially by a flurry of dealing making around the Senate bill (Medicare or Medicaid carve outs for Florida, Louisiana and Nebraska most visibly).

The late January loss of Ted Kennedy’s seat to an insurgent “Tea Party” Republican, Scott Brown, was an unmistakable warning sign that even formerly unassailable Blue State Democrats were now at risk. Political pundit Charlie Cook, who follows the Congressional races at a microscopic level, wrote recently that the Democrats have been in free fall since August. They lost gubernatorial races in New Jersey and Virginia, county executive races in solidly Democratic Fairfax County (VA) and Westchester and Nassau Counties (NY). A surge of inconvenient scandals- David Paterson, Charles Rangel and Eric Massa- all in New York- have further tarnished Democratic credibility. Cook placed the odds on the Democrats losing the House this November at 50-50 and sliding.

On the eve of the Presidential health reform “summit”, a Newsweek poll revealed that independent voters, crucial to re-election of Democratic moderates, opposed passage of health reform by a stunning 62-29% margin. Despite the White House’s feeling that the President could paint the Republicans into a corner and blame them for halting health reform, a Politico.com reader poll after the summit suggested the Republicans decisively outpointed the President (52%-19%) by stressing the fiscal and economic risks of the bill. There aren’t a lot of undecided voters left on the health reform issue- and strongly “anti-” sentiment outruns strongly “pro-” sentiment by almost two to one.

Now the White House and Democratic leaders are in the final scramble to find votes to send the President something he can sign and declare this endless and divisive process over. Speaker Pelosi suggested last week that, regardless of the damage they may suffer at the polls in November, House Democrats owe her and the President a reaffirmation of their support. Pelosi basically ordered her troops to swallow their reservations about this bill and fall on their swords.

Gloria Borger of CNN reported late last week that a “senior White House aide” characterized the coming vote on health reform as “the last helicopter out of Saigon”, the most unfortunate political metaphor of the Obama era thusfar. (For younger people, that helicopter was ferrying South Vietnamese collaborators with the United States off the roof of the CIA compound before the North Vietnamese Army flooded into Saigon). What did the “senior White House aide” mean? That the Communists are coming and congressional Democrats need to save themselves and run for the hills? It sure doesn’t sound like a clarion call to do the right legislative thing.

It isn’t the Communists that are coming. It’s a lynch mob. And the angry horde is going to discriminate between “progressives” and moderates. They are simply going to find and hang as many public officials as they can get their hands on – incumbent Congresspeople, Senators, Governors, state legislators, county executives. Unfortunately for the Democrats, the majority of those incumbents are Democrats. I’ve not seen such a toxic electoral atmosphere in my lifetime.

If she cannot find the votes to pass health reform, Speaker Pelosi will be deflecting blame and knifing her White House colleagues in the back all the way to the guillotine. If it passes, it will be in spite of, rather than because of, her advocacy. By maliciously complying with the President’s mandate, Speaker Pelosi and her arrogant, tone-deaf management of the legislative process badly damaged the prospect for lasting health reform. She should scramble for a seat on that last helicopter herself.

Leave a Reply

Thanks for a very interesting web site. Where else could I get that kind of info written in such an ideal approach? I’ve a project that I’m simply now operating on, and I’ve been at the look out for such information.

- Share

Guest

jd

Mar 9, 2010

I’m well aware of the history of Vietnam. As I made clear, my comment was about what could have been meant by “the last helicopter out of Saigon.” The quote made it appear that the vote to pass reform is being compared to the last helicopter, and that the aftermath will be defeat at the polls in November. In that case, the vote is an attempt to salvage something and do the right thing, however partial and incomplete, and even though (electoral) defeat is coming. This is contrary to Jeff Goldsmith’s interpretation of the statement. In any case, Jeff and I agree that whatever analogy was being made, it wasn’t a very good one. As in, it doesn’t really describe the situation with the health care vote. I hope we can be done with that discussion now.
About those the snide (I mean, heartfelt) comments about docs in their 30s, presumably in response to my statement that good things are coming from the younger generation of physicians: The point is not that younger is better. Seasoning matters, which is why I said good things are “coming,” as in, over the course of 20-30 years as the physicians gain experience and dominate the field. The point was that the current crop of docs 55 and up is the most resistant to certain reforms that many, many folks who study this for a living say are critical to improving quality while curbing cost growth.
Related to this, a nice article in the Times about reigning in the physician cowboy culture.

- Share

Guest

Jeff Goldsmith

Mar 9, 2010

Harris, my point was that you bridge the gaps in private through consensus building, not by trapping your members and then have to negotiate embarrassing givebacks on key issues in public. Perhaps those gaps were unbridgeable, but we’ll never know. Pelosi’s poor political judgment badly damaged this process and squandered the considerable advantage of huge Congressional majorities by airing a lot of the party’s dirty linen in public.
It may be, as Matthew suggested, that the party is unworkably broad ideologically , but master politicians of both parties (Roosevelt and Reagan) made that difficult bridging process look easy. The process was also badly damaged by tossing Daschle under the bus, and by the loss of Ted Kennedy, who had enough credibility with all the Democratic factions to have worked something out.

- Share

Guest

MD as HELL

Mar 9, 2010

When do we start the battle to reform reform? This will surely crater, pass or not pass.
The young doctors do not work like their elders, but patient volume rquires docs like me and not like the life-style crowd. If this becomes law, the post office at Christmas will look like heaven compared to your ER at 3 AM.

- Share

Guest

Harris Meyer

Mar 9, 2010

Jeff, I’m baffled by this paragraph: “Moderate Democrats also objected to subsidizing private coverage of abortions and to any enrollment of people in the US illegally (roughly 7-8 million of the uninsured). It might have been possible to address these concerns “privately”, e.g. in the initial drafting process…”
As far as I know, the House bill at no point would have subsidized coverage of illegal immigrants, despite Republican claims to the contrary. And it appears that the conservative Dems’ concern about abortion coverage blew up at the very last minute last fall, and was resolved by Pelosi through the Stupak amendment.
You fail to acknowledge that making both the conservative Dems happy while satisfying the core Dem constituencies of women, Hispanics, and single-payer advocates was a difficult or impossible task.
This piece isn’t up to your usual high standards of analysis.

- Share

Guest

archon41

Mar 9, 2010

All together now: C’est la lutte finale. . .

- Share

Guest

ExhaustedMD

Mar 9, 2010

So, all you smart thirtysomethings, get up and lead the way, make the world the wonderful place you envision it, with your laptops leading the way!
He he he, your age group is no better, it is the arrogance and cluelessness leading the way in that comment! Dismiss generations ahead of you? Be ready for the one following you to repay you in spades!!!

- Share

Guest

archon41

Mar 9, 2010

When you get right down to it, all the really smart people are in their 30’s.

“The Left has also raised the banners of jihad against insurers”
The ruler41 is correct regarding this, but not the criticism regarding weak proposals to lessen or roll back costs. That comes in the next reforms that will certainly occur.
Forget “socialist”, I believe in “communism”. Insurance in a way is communism. Jeder nach seinen Fähigkeiten, jedem nach seinen Bedürfnissen is a slogan for community-rated insurance and one that should be followed.
“loggorheaic” logorrheic = logo(r)- < logos=word rhe=flow -ic = adjectival ending -a = substantive ending. Doubling of r consonant when beginning and ending same consonant of joined Greek-origin words. Doesn't anyone know etymology in this weblog?
"We abandoned millions of our allies in that war to death camps and two decades of political repression and stagnation"
Not an accurate summary of the denouement of the Vietnam escapade, but then again this is not the place for that discussion. Were all collaborators with the Nazis in occupied countries during WWII forgiven by those who were partisans fighting to evict the Germans after the departure of the Germans?
"However I am more than amused by the Kaiser survey which said that 60% of Americans opposed the bill until they were told what was in it, when 60% then supported it!"
This of course says it all. What if the benefits of single payer/insurer among other changes beneficial to the "people" were explained clearly to those "people"? Overwhelming support for it and other features.

- Share

Guest

Jeff Goldsmith

Mar 9, 2010

Jd, we lost the Vietnam War. We abandoned millions of our allies in that war to death camps and two decades of political repression and stagnation. The last helicopter saved thirty people. I found the metaphor bizarre in context.
Also agree that burnt out docs ought to go do something else. I don’t want an Exhausted MD taking care of me. I want someone who really wants to see me when I walk into the exam room.
Agree emphatically that there are lots of positive trends w/ the younger docs, including the work-life balance thing and a new and much more constructive view of HIT. It’s just the quantitative shortfall of them; it’ll take a decade or more to fix. And it isn’t just primary care docs that are short. general surgery has almost disappeared, as have a lot of the 24/7 specialties except ER).
Matt, don’t pray for total collapse. It will hurt, again, millions of people before we get them help. We just need pragmatic, consensus oriented, thoughtful political leadership. We’ve got it in the White House. Now we need it in Congress. If we keep driving off the thoughtful people and send in wave after wave of ideologues (of the leftward or rightward persuasion), we’ll never get the government we need to fix it. And of course, if you ask people about the benefits of these bills, they’ll say “sure. bring ’em on”. It’s the price you pay for them that’s at issue. . .
Maggie, isn’t the Kool-Aid starting to make you sleepy?

- Share

Guest

jd

Mar 8, 2010

All this talk of physicians retiring does not fill me with dread. For one thing, the older ones are the most resistant to necessary change. If a pilot says: “Screw the FAA, flight protocols, safety checks and all that stuff, my instinct and personal experience tells me how to fly a plane,” we’d think he was a nutty old codger. But we are supposed to honor physicians for the same “do it my way” attitude? Good riddance! Physicians in their 30s are on board with the HIT, evidence-based, group practice train to a far greater extent. Good things are coming to the recipients of care from this generation.
Also, the physician shortage such as it exists or may soon exist, was in large part created through a bottleneck in medical school and a preference for more lucrative specialist careers (money again!), not a lack of demand to become a physician. As this article points out, only one medical school in the entire US was created in the 80s and 90s. Supply did not keep up with demand, and now finally lots of new schools are opening and current ones are expanding. And of course, we will continue to hire new physicians from abroad to fill gaps. Not an ideal solution by any means, but an unfortunate necessity in some low income and rural places for now.
Matt, I don’t think we’ll reach a crisis moment leading to single-payer, but other than that you are dead-on about the forces at work.
Nate, I’m not sure what motivated the silly swipe about the last helicopter being noble. What does the nobility (or not) of that act have to do with the justness of the war as a whole, or how well-run it was? It’s perfectly possible to do the right thing at a given moment even after screwing up something much bigger which preceded it. The whole premise of the example is that the final deed follows something that has gone wrong, so I didn’t ignore that but rather used it in my interpretation. I do find it odd that you disrespected the final efforts to go back for our allies to save them from torture and death. In any case, I was trying to make sense of the phrase in context, which didn’t seem to fit the spin Jeff Goldsmith was putting on it. Still doesn’t.
Jeff, you say the one comment worth rereading is Exhausted’s “heartfelt” one. Being heartfelt is not enough. Opinions have to be supported by data. Is there anyone posting in this thread who (aside from bouts of sarcasm) isn’t earnest and heartfelt? Exhausted is not more heartfelt than the rest of us. It seems to me that he has fewer coping mechanisms for adversity than the rest of the posters.

- Share

Guest

Nate

Mar 8, 2010

“if we dont have this we end up at 30% uninsured and 25% of GDP in ten years”
On the bright side we know for a fact no liberal projection on healthcare spending has been correct in 50 years so there is an excellent chance Matt’s doomsday projection will never happen.

Seems like the President is now doing what he should have done last spring and summer.http://www.nytimes.com/2010/03/09/health/policy/09health.html
I agree with Maggie, they either have the votes or they are committing mass suicide and it doesn’t sound like suicide to me.
“The United States Congress owes the people a final up or down vote on health care,” Mr. Obama said. “It’s time to make a decision. The time for talk is over.”

- Share

Guest

archon41

Mar 8, 2010

Or perhaps there will come a point in time at which the politicians who are demanding “expansion of coverage” as a quid pro quo for addressing costs are ejected from office, and a point in time at which employers can no longer afford to fund policies of insurance which encourage their employees to insist on every available benefit, regardless of cost.

We frequently accept crossposts from smaller blogs and major U.S. and International publications. You'll need syndication rights. Email a link to your submission.

WHAT WE'RE LOOKING FOR

Op-eds. Crossposts. Columns. Great ideas for improving the health care system. Pitches for healthcare-focused startups and business.Write ups of original research. Reviews of new healthcare products and startups. Data-driven analysis of health care trends. Policy proposals. E-mail us a copy of your piece in the body of your email or as a Google Doc. No phone calls please!

THCB PRESS

Healthcare focused e-books and videos for distribution via THCB and other channels like Amazon and Smashwords. Want to get involved? Send us a note telling us what you have in mind.
Proposals should be no more than one page in length.

HEALTH SYSTEM $#@!!!
If you've healthcare professional or consumer and have had a recent experience with the U.S. health care system, either for good or bad, that you want the world to know about, tell us about it. Have a good health care story you think we should know about? Send story ideas and tips to [email protected].